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TREATMENT from Rockwood: The Shoulder on MD Consult
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Rockwood: The Shoulder, 4th ed. TREATMENT

Nonsurgical
Strengthening of the deltoid muscle and remaining rotator cuff muscle can result in improved function. Injection of corticosteroids into the joint can be tried to relieve pain in combination with oral analgesics. This can be sufficient in patients with mild or moderate pain and loss of function. The use of repeated steroid injections is discouraged.
Arthroscopic Surgery
Arthroscopic dbridement and biceps tenotomy has been reported to improve function in patients with cuff tear arthopathy. [50,51] This can be tried, particularly in elderly patients with low demands and in patients not willing to undergo major surgery. It might relieve pain but does not restore function in pseudoparalytic shoulders.
Arthrodesis
Good pain relief can be achieved by performing an arthrodesis in patients with cuff tear arthropathy (Fig. 2313). In patients with pseudoparalysis, an arthrodesis can also improve functional range of motion. However, increased load on the thoracoscapular articulation and the acromioclavicular joint can cause pain from these locations. In 1991, Arntz and colleagues reported 10 patients who underwent arthrodesis for irreparable cuff tears. [52] The arthrodesis improved active forward elevation by a mean of 15 degrees. They concluded that arthrodesis could be indicated in patients with massive irreparable cuff tears and significant deltoid deficiency or in young patients with significant strength demands at low angles of flexion.
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FIGURE 23-13 Arthrodesis in a 54-year-old man for massive rotator cuff tear and osteoarthritis.
Resection arthroplasty is a poor solution that yields an unstable, nonfunctional, often painful shoulder and thus should not be carried out as a primary surgical treatment in these patients.
Anatomic Unconstrained Arthroplasty Total Shoulder Arthroplasty

The superior migration of the humeral head in patients with cuff tear arthropathy creates eccentric load on the glenoid component. This has been called the rocking horse effect; it results in increased rates of loosening. [53] In 1991, Lohr and Cofield reported better pain relief in total shoulder arthroplasty compared to hemiarthroplasty in 22 patients with cuff deficiency, but an increased incidence of radiographic and clinical loosening. [54] Similar findings were reported by Franklin and colleagues in a study where three of nine patients with cuff deficiency needed early revision after total shoulder arthroplasty. [53] Due to this increased risk of glenoid loosening, anatomic total shoulder replacement is not recommended in patients with significant cuff deficiency.
Hemiarthroplasty
Hemiarthroplasty has been the treatment of choice for the arthritic shoulder with cuff deficiency. Due to the clinical success of the Grammont reverse ball-and-socket arthroplasty, the indication for using a hemiarthroplasty is more limited. The results after hemiarthroplasty are unpredictable, and Neer proposed the term limited-goal rehabilitation for these patients. [1] Persistent pain has been reported in 6% to 53% of the
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patients after hemiarthroplasty; active elevation is reported at 60 to 70 degrees preoperatively improving to 90 to 120 degrees postoperatively (Table 23-2). [3,5562]
TABLE 23-2 -- Results of Hemiarthroplasty in Arthritic Rotator CuffDeficient Shoulders Reference Pollock et al, [59] 1992 Arntz et al, [55] 1993 Williams and Rockwood, [61] 1996 Field et al, [57] 1997 Zuckerman et al, [62] 2000 Sanchez-Sotelo et al, [60] 2001 Mean Follow-up No. (mo) 30 41 18 25-122 21 48 16 33 15 28 33 60 Preoperative Elevation (degrees) 64 66 70 60 69 72 Postoperative Elevation (degrees) 108 109 120 100 86 91
An oversized humeral head has been suggested to create a better articulation with the acromion and the coracoacromial arch. However, Sanchez and colleagues could not find a correlation between head size and function, and there are several disadvantages. An oversized humeral head can increase the joint reaction forces and possibly more-rapid bone resorption. [60] A large head makes it more difficult to partially repair the rotator cuff. A larger head puts the center of rotation more lateral than inferior, which contributes a biomechanical disadvantage to the deltoid by shortening the lever arm. Any attempt to even partially repair the deficient rotator cuff becomes much more difficult with a larger humeral head. Several techniques have been proposed and used for this purpose. Pollock, [59] Cantrell and Burkhead, [63] and DiGiovanni [3] advocated the use of subscapularis tendon transfer to a more superior position as a method for superior stabilization of the humeral head. The subscapularis tendon can then be reinserted into the top of the greater tuberosity. The use of anatomic, or slightly smaller, humeral head size facilitates this transfer. This option is limited to patients who have a functional unshortened subscapularis tendon. In an attempt to improve results of hemiarthroplasty in patients with cuff tear arthropathy, a specific head has been designed: the CTA head (Fig. 23-14). It has a lateral extension over the greater tuberosity, producing a greater arc for articulation against the glenoid fossa and the undersurface of the acromion and coracoacromial arch. The head size is anatomic, thus there is no overstuffing of the joint.
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FIGURE 23-14 Hemiarthroplasty with a laterally extended cuff tear arthropathy (CTA) head. A, CTA prosthesis. B, Diagram of installed prosthesis.
A size-adapted head, which does not decease the lever arm significantly and which articulates under the acetabularized coracoacromial arch as a fulcrum, was introduced as a specific implant in hemiarthroplasty a few years ago. The prosthesis design, with its greater lateral coverage of the head, prevents the painful impingement of the eroded and uncovered greater tuberosity against the acromion in abduction and flexion and in external rotation (Fig. 23-15). Early clinical results [64,65] show encouraging outcomes in patients whose joint still is biomechanically balanced and stable and whose humeral head (i.e., center of rotation) has not migrated extremely anterosuperiorly. These patients have only a minor amount of static and dynamic superior displacement of the center of rotation. The studies clearly demonstrate that a nearly intact and well-functioning subscapularis and an intact coracoacromial arch are important prerequisites for a good clinical outcome of this type of shoulder arthroplasty for cuff tear arthropathy.
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FIGURE 23-15 Rationale for a laterally extended cuff tear arthropathy (CTA) head. Left, Abduction and external rotation are limited due to painful impingement against uncovered greater tuberosity. Dashed red lines radiating up and to the left indicate impingement. Right, The laterally extended CTA head allows a greater arc of motion in abduction and greater external rotation by coverage of the greater tuberosity.
Bipolar Arthroplasty
A bipolar arthroplasty has a humeral component with a stem and a fixed head upon which a mobile outer shell is placed, usually through a snap-fit mechanism (Fig. 23-16). [6670] The idea was to have a hemiarthroplasty acting like a total shoulder replacement by having motion between the fixed head and the outer shell.
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FIGURE 23-16 Radiograph showing a bipolar arthroplasty with varus tilting of the outer shell of the bipolar prosthesis, superior migration, and secondary erosion of the lateral clavicle and the acromioclavicular joint.
In 1988, Swanson and colleagues reported on 35 shoulders (rheumatoid arthritis in 20, degenerative arthritis in 10, post-traumatic lesions in 5) with a mean follow-up of 63 months. [67] Complete pain relief was seen in 15 patients, and there was a modest increase in range of motion. The bipolar implant was recommended in patients with severe arthritic changes with vertical subluxation of the humeral head, namely, cuff tear arthropathy. Worland and coworkers reported on 33 patients with cuff tear arthropathy treated with a bipolar arthroplasty; 22 of these patients had a follow-up between 24 and 48 months. [69,70] In these 22 patients, active forward elevation increased from 38 to 67 degrees, and external rotation increased from 12 to 51 degrees. UCLA score increased from a mean of 9.2 to 26. One patient underwent revision 4 years after surgery. Lee and Nieman reported on 13 patients with rotator cuffdeficient arthritic shoulders that underwent bipolar arthroplasty. [66] Seven patients had rheumatoid arthritis and the rest had revisions of failed previous reconstructions, including 5 total shoulder replacements. The rheumatoid group had good pain relief but only a modest improvement in range of motion. Today, the bipolar arthroplasty is not widely used. The outcome is unpredictable and there has been concern with overstuffing the joint.
Reverse Arthroplasty
Reverse arthroplasty prostheses have the convex head on the glenoid side and the concave component on the humeral side. Most of the early designs failed on the glenoid side due to a small glenoid ball with lateralized center of rotation. The present design is based on the concept of the Delta prosthesis designed by Paul
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Grammont in Dijon, France. The biomechanical principles of the reverse design have already been discussed. The Delta prosthesis relies on the deltoid muscle for function and stability. In 1993, Grammont and Baulot reported on the first 14 cases with the Delta reverse ball-and-socket arthroplasty with good pain relief and improved function. [13] It can give excellent pain relief and restoration of active range of motion in patients with painful pseudoparalytic shoulders. [13,14,45,7174] Due to lack of long-term follow-up studies, the Delta prosthesis is primarily recommended in older patients with cuff tear arthropathy. Many patients who would have received a hemiarthroplasty in the past are now treated with the reverse arthroplasty. However, patients with good active range of motion despite arthritis and a massive rotator cuff tear (biomechanically balanced shoulder) can still have a good outcome with a hemiarthroplasty.
Seebauer's Preferred Approach: CTA-Head Hemiarthroplasty Indications

The ideal patient for a CTA-head hemiarthroplasty is one with a biomechanically balanced shoulder without an anterior escape of the humeral head. That means patients who have a painful arthritic shoulder but without a complete functional impairment (pseudoparalysis). In the clinical situation that means that patients have a forward flexion of more than 100 degrees, which they can hold for a few minutes and without anterior escape of the humeral head (no dynamic superior escape). X-rays should be analyzed to determine whether the joint is still centered and meeting the criteria for type Ia or Ib according to our classification (see Fig. 23-10). In very painful shoulders it is important to determine whether the functional impairment is pain related or really a structurally caused pseudoparesis. In these cases we recommend an injection test with a minimum of 20 mL of local anesthesia and to retest the patient's function 30 minutes after the injection. Patients whose shoulder function improves and who attain the criteria after the injection are good candidates for a hemiarthroplasty with the CTA-head prosthesis. In doubtful cases it is sometimes helpful to do a dynamic fluoroscopic examination with resisted flexion and abduction to check the stability of the joint against superior translation. Sometimes this is the only way to identify patients with a dynamic type of superior instability. Patients with a static type of superior dislocation are not candidates for joint replacement with hemiarthroplasty with a CTA-head prosthesis. Patients who have a mild superior translation and good residual function (some superior migration of the center of rotation but residual resistance against complete superior escape because of an intact coracoacromial arch) are more difficult to assess. In this specific patient group we recommend the CTA-head prosthesis in younger patients (<70 years who have an intact subscapularis and an untouched coracoacromial arch. Patients older than 70 years or who have massive anterior-superior cuff defects or insufficient coracoacromial arch are better candidates for a reverse shoulder arthroplasty. In preparation for the operation we recommend as a prerequisite x-ray films in three planes (true anteroposterior, axial, outlet) to determine the amount of static superior displacement of the humeral head, the glenoid morphology, and the overall bone quality. A magnetic resonance image (MRI) is desirable for evaluating the extent of the rotator cuff tear and the state of the residual cuff muscle.
Anesthesia and Patient Positioning

We carry out the procedure normally with a combination of interscalene block and a light general anesthesia. If there are severe contradictions, the procedure could be also carried out with an interscalene block alone. The patient is placed in the beach chair position.
Surgical Approach
After examining the range of motion and the stability patterns, we make a classic anterior deltopectoral incision of 8 to 10 cm. We open the deltopectoral interval and remove all adhesions and chronic synovitic tissue in the subacromial, subdeltoid, and subcoracoid bursae. If there is a contracture of the pectoralis major, we also release the superior 1 to 2 cm of the pectoralis major tendon insertion. The coracoacromial ligament is kept strictly intact. The amount of the rotator cuff is evaluated and the condition of the subscapularis tendon is thoroughly checked. If there are any doubts on the quality of the subscapularis tendon or if the defect involves more than the superior third of the subscapularis tendon, the indication for a hemiarthroplasty with a CTA-head prosthesis has to be reassessed and sometimes changed to reverse shoulder arthroplasty. If the subscapularis is intact, we release only the necessary amount of superior fibers from their humeral insertion to get a sufficient approach for dislocating and resecting the humeral head. In cases with extended
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posterior-superior cuff tears, sometimes detachment of only the superior third of the subscapularis tendon is enough to get a sufficient approach to easily produce an anterior-superior dislocation of the humeral head. (Fig. 23-17) If the capsule is tight, it is possible to release the capsule from the tendon without detaching the inferior half of the tendon. We do this by coming from the inside, carrying out the dissection of the anterior and inferior capsule from the inside, and holding away the attached subscapularis tendon with a Langenbeck retractor anteriorly. The biceps tendon, if still present, is always tenotomized and fixed extra-articularly by simple transosseous sutures in the bicipital groove or beneath the pectoralis major tendon insertion. The intra-articular part of the tendon is cut off. The osteophytes are removed stepwise along the anatomic neck, starting at the anteriorsuperior corner of the bicipital groove and working inferiorly and posteriorly. This gives additional clearance for head dislocation and resection without the necessity of completely detaching the subscapularis. Subscapularis integrity and good subscapularis function are the key factors for a good final clinical outcome in treatment of balanced (compensated) cuff tear arthropathy with a hemiarthroplasty and the CTA-head prosthesis.
Head Resection
The head can be resected using the intramedullary or the extramedullary resection guide of the Global Advantage system. (Fig. 23-18) The radius of curvature of the resected head is measured by a template. If the head is severely deformed, the radius of the glenohumeral joint orin cases with some deformation of the glenoidthe radius of curvature of the new articulation underneath the coracoacromial arch and the superior part of the glenoid is measured using the opaque testing components of the glenoid trials (Fig. 23-19). After the head resection, the humeral shaft is prepared the same as for the Global Advantage stem: reaming the canal, opening the epiphysis with a box osteotome, and broaching the canal with the appropriate broach, which is simultaneously the trial prosthesis.
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FIGURE 23-18 Head resection. A, Extramedullary. B, Intramedullary guided.
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FIGURE 23-19 Measuring head diameter by template (top) or indirectly by glenoid trial. The cuff tear arthropathy (CTA) heads are available in diameters of 44 to 56 mm (bottom), with two head heights (18 and 23 mm) for each diameter.
At this point, the decision must be made whether to use a regular modular head or the laterally enlarged CTAhead prosthesis. If only the superior part of the greater tuberosity is uncovered and the infraspinatus tendon insertion is still intact to a great extent, a hemiarthroplasty with a regular modular head (centric or eccentric) of appropriate size (radius and head) is recommended. The CTA-head prosthesis is recommended if major parts of the greater tuberosity are uncovered. Attempts at partial reconstruction of the posterior-superior cuff are only undertaken if the tendon quality is appropriate, if tendon retraction is no greater than grade 2 according to Patte, and if fatty infiltration of the corresponding muscle belly of the infraspinatus is no greater than grade 2. That means only if there is a predictable healing of the repair should it be attempted. Partial repairs at the expense of tightening the soft tissue envelope and therefore reducing the achievable range of motion are not reasonable.
Preparation of the Greater Tuberosity

Once the final decision for reconstruction with a CTA-head prosthesis is established, a specific resection guide for the greater tuberosity is mounted to the trial prosthesis (broach) (Fig. 23-20) and the greater tuberosity is resected (Fig. 23-21). The resection jig is removed, and the corners are trimmed with a rongeur or a bur (Fig. 23-22). The trial head of the appropriate diameter that best fits the radius of curvature of the glenoid and the resected head is chosen (Fig. 23-23).
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FIGURE 23-20 Resection tool for greater tuberosity mounted to a Global Advantage trial broach. A, Attachment of the fixation device for the greater tuberosity cutting guide on the trial stem. B, Fixing the cutting guide for the greater tuberosity to the trial stem (view from above).
FIGURE 23-21 Resection of the tip of the greater tuberosity. A, Dotted line illustrates bone to be removed. B, Saw blade gliding on the cutting guide.
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FIGURE 23-22 Final trimming of greater tuberosity by rongeur or bur. Arrows point to bone to be removed.
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FIGURE 23-23 Attaching the trial head and adjusting the bony contours for perfect articulation beneath the coracoacromial arch.
Head Size
There are four diameters (44, 48, 52, and 56 mm) and two heights (18 and 23 mm) for each diameter available. The prosthesis must be tested to determine which height gives the best stability and lowering of the center of rotation without deteriorating the capacity of the soft tissue envelope and consequently the range of motion. The smoothness and stability of articulation beneath the coracoacromial arch has to be considered. Therefore the translation capacity in the anteroposterior plane has to be tested and should be about 50% of the glenoid extent. The internal and external rotation with the arm abducted should achieve a minimum of 75 degrees. The opposite shoulder should be easily reached in a cross-body motion. Care must be taken not to choose a head that is too large and hangs over the anterior or posterior resection level of the head. An anterior overhang threatens the subscapularis and leads to hardware impingement against the tendon from inside the joint, with consequent failure of the tendon insertion. Therefore, in severely femoralized heads with extended superolateral osteophytes, the posterolateral aspects of the humeral head must be contoured inferior to the outlines of the most suitable prosthetic head (Fig. 23-24; see Fig. 23-23) to get a perfect articulation with no impingement of the proximal humerus beneath the acetabularized coracoacromial arch.
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FIGURE 23-24 Definitive implant in place. (Courtesy C. Basamania, MD, Duke University).
After testing is finished, the broach is removed and the definitive implant is assembled. The implantation could be done with or without cement. We prefer a cementless implant in case of a possible later revision to a reverse shoulder arthroplasty. For a cementless implantation in cases with poor proximal cancellous bone, we like to do some impaction bone grafting specifically on the medial calcarepimetaphyseal junction to produce a good press-fit and to avoid medialization and varus malalignment of the prosthesis.
Implantation and Subscapularis Reattachment

Before implantation, heavy (minimum No. 2) transosseous nonabsorbable sutures are placed at the resection level of the subscapularis detachment, passing through the bone tunnels, which are far enough away from the resection line to prevent a pullout of the suture (Fig. 23-25). We prefer to do the bone-tunneling with the sutures in a U-type mattress style to provide a good bony bridge against pullout. After the prosthesis is implanted, the proximal humerus is trimmed laterally and posteriorly to create a perfect femoralized shape of the proximal humerusarthroplasty complex. The detached subscapularis tendon is fixed with MasonAllen stitches with the prepositioned transosseous sutures (minimum of three). After thorough irrigation we bring in a suction drain and then close the deltopectoral interval and subcutaneous tissue layer and the skin.
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FIGURE 23-25 Subscapularis reattachment. A, Sutures placed for subscapularis reattachment. B, Subscapularis reattached.
Postoperative Care
Patients are positioned in a sling and kept in a sling for a minimum of 2 weeks during the day and for 6 weeks at night. After 2 weeks, the sling is primarily used to prevent accidental external rotation, which places the subscapularis repair at risk. Patients are started with active assisted flexion and abduction exercises on the first postoperative day. We limit the external rotation for the first 2 weeks to 0 degrees, then for 2 weeks to 15 degrees and for another 2 weeks to 30 degrees. Patients are allowed to use the arm for self-care from day 1 on. Resistance exercises are started at 6 weeks for the residual cuff, with the exception of the subscapularis. Resistance exercises are added for the subscapularis after 12 weeks.
Ekelund's Preferred Approach: Reverse Arthroplasty

The reverse arthroplasty can be inserted through a standard deltopectoral approach. However, Grammont favored a superior deltoid-splitting approach for primary cases and the deltopectoral approach for revisions. The superior splitting approach gives excellent exposure of the glenoid, and there is no need to cut the remaining rotator cuff tendons. If a deltopectoral approach is used, the subscapularis tendon needs to be divided, and there may be difficulties reattaching this tendon. A deltopectoral approach has been associated with higher dislocation rates, and the superior deltoid-splitting approach has been reported to have a higher incidence of notching. [75] We prefer the deltoid-splitting approach for primary Delta cases and the deltopectoral approach for revisions.
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Patient Positioning
The patient is placed in the beach chair position. The sterile field should include the upper arm down to the elbow.
Surgical Exposure
The superior deltoid-splitting approach (McKenzie-type approach) is described here. A 6- to 7-cm skin incision is made along the lateral edge of the acromion along Langer's lines. After subcutaneous dissection, the deltoid muscle is split. Starting from the acromioclavicular joint, about 5 to 6 mm behind the tip of the acromion, the deltoid is split in a straight lateral direction, extending 4 to 5 cm from the acromion edge. The deltoid can be released from the tip of the acromion by removing soft tissue only or by releasing the deltoid insertion with a small piece of bone. The coracoacromial ligament is removed and a small acromioplasty is performed to create more room. The subacromial bursa is removed and adhesions are released. A self-holding Gilpi retractor is used. In most cases, the humeral head can now be dislocated superiorly into the wound by extension and external rotation of the arm and by pushing the humerus superiorly by applying a superior force on the elbow (Fig. 2326). The remnants of the rotator cuff are inspected. If the infraspinatus or teres minor (or both) is present, care is taken to protect these during surgery to maintain external rotation postoperatively. The subscapularis should be preserved, although sometimes, particularly in stiff shoulders, the superior edge of the subscapularis needs to be removed. If the biceps tendon is present, a tenotomy or a tenodesis is performed.
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FIGURE 23-26 Superior-lateral approach to the shoulder in a patient with a massive rotator cuff tear. The head is displaced anterosuperiorly for humeral head resection.
The humeral canal is opened by removing the hard sclerotic bone on the top of the humeral head to introduce the reamers (Figs. 23-27 and 23-28). After reaming to the appropriate size, a cutting jig is applied to perform the head cut (Fig. 23-29). We perform the head cut in neutral, that is, with no retroversion (see Fig. 23-29).
FIGURE 23-27 The forearm is used as a reference point to determine the version of the head cut. Red lines indicate degree of retro- or anteversion of the humeral component relative to the forearm.
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FIGURE 23-28 The humeral canal is opened and reamed. The red dot shows the point for reaming. Red dot shows entry point.
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FIGURE 23-29 The cutting jig is applied.
Glenoid Component
A special retractor is put underneath the glenoid to push away the humerus to expose the glenoid (Fig. 23-30). A complete circumferential release is made around the glenoid to define the bony anatomy.
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FIGURE 23-30 A special glenoid retractor (fork retractor) is placed under the glenoid to give the surgeon an appropriate view of the glenoid surface.
One of the most important steps of the procedure is correct placement of the glenoid component. It should be placed as low as possible to reduce the risk of notching (Fig. 23-31). A superior tilt must also be avoided (Fig. 23-32). A positioning guide is used to place the metaglene base plate at the inferior border of the glenoid fossa. A guide pin is introduced. A small, cannulated, curved back reamer is used to prepare the surface (Fig. 23-33). Excessive reaming should be avoided and, when possible, the subchondral bone should be preserved. A handheld reamer is then used to remove bone superiorly and, if necessary, anteriorly, posteriorly, or inferiorly to create a flat surface for the glenosphere (the ball) (Fig. 23-34).
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FIGURE 23-31 The metaglene component should be placed as low as possible in the lower part of the circle. The red dot indicates the center of the circle. Red dot shows entry point for the guide pin.
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FIGURE 23-32 A guide pin is placed using the aiming guide. Avoid superior tilt.
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FIGURE 23-33 A cannulated reamer is used to prepare the glenoid surface for the metaglene base plate.
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FIGURE 23-34 The hand-held cannulated reamer is used to complete the preparation.
A central drill hole is made for the central peg. The guide pin is removed and the metaglene component is introduced. The screw fixation starts with the inferior screw, which is aimed at the inferior bony collar of the scapula (Fig. 23-35). This usually means that the inferior hole is rotated slightly posterior and the superior hole is in a slightly anterior position. Ideally a 36- to 42-mm screw is used. The superior screw is placed. The drill hole is aimed at the base of the coracoid. Usually a 30- to 36-mm screw is used. The new reverse design gives the surgeon freedom to place the screw in different angles to find the best bone. After the inferior and superior screws are placed, they are locked to create a locked-angle configuration. The anterior and posterior standard or locking screws are introduced, completing the metaglene fixation (Fig. 23-36).
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FIGURE 23-35 With a drill guide, the holes for the screws are drilled, starting with the inferior screw. The locking screws are polyaxial.
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FIGURE 23-36 All four screws in place, completing the metaglene fixation.
Preparation of the Humerus

The method for final preparation of the humerus depends on if a cemented or noncemented implant is used. A monobloc cemented component is available with two different epiphyseal sizes and different stem sizes. The noncemented humeral component is modular, allowing the surgeon to adapt the stem to the anatomy of the patient by changing version and incorporating the offset of the post into the final component. A guide is introduced into the humeral canal, and the proximal reaming is performed with the appropriate cannulated reamer (Fig. 23-37).
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FIGURE 23-37 With a guide in place (left), the proximal humeral reaming is performed (right).
Trial Reduction
A trial glenosphere is introduced. There are two sizes, 38 mm and 42 mm, and both are available as standard and eccentric designs (Fig. 23-38). The advantage to the 42 mm is that it creates a greater overhang inferiorly, which reduces notching. However, in small patients or tight shoulders, it may be necessary to use the 38-mm glenosphere.
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FIGURE 23-38 Trial humeral component.
The chosen humeral component is introduced (Fig. 23-39) and a polyethylene trial insert is chosen (Fig. 2340). There are three different heights: 3, 6, and 9 mm. They are available as standard design based on the previous Delta arthroplasty or as hypermobile design with a reduced cup depth of 2 mm, giving a greater range of motion but with less stability.
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FIGURE 23-39 Trial glenosphere in place.
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FIGURE 23-40 Both trial components with insert in position. Stability testing is performed.
After reduction, the stability is tested. The self-retaining retractors are removed and the arm is placed in various degrees of rotation, flexion, and abduction. The arm is adducted to see that the two components do not separate or subluxate. Separation or subluxation usually is caused by impingement of the humeral component or humeral bone on the scapula neck, which needs to be corrected. In extension and external rotation, a small opening between the two components can be seen, but the shoulder should remain stable. When the arm is pulled downward, there should be no separation of the two components. If necessary, the inserts are changed until satisfactory stability is achieved. In a few cases, particularly in revisions, it may be necessary to lengthen the humeral component with a 9-mm lengthener and then try the inserts to achieve stability. When stability is satisfactory, the definite glenosphere is placed on the metaglene (Fig. 23-41) and the chosen humeral componentcemented or noncementedis placed in the humerus (Fig. 23-42). We recommend performing a new trial reduction to see that the chosen insert is still giving good stability because the final position of the implants may be different compared to when the trial reduction was performed.
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FIGURE 23-41 The definitive glenosphere is attached to the metaglene base plate.
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FIGURE 23-42 The humeral component and the chosen polyethylene insert are inserted.
Wound Closure
After irrigation, the deltoid muscle is reattached to the acromion through nonabsorbable osteosutures. A drain is used until the day after surgery. The deltoid split is closed with absorbable sutures. The arm is placed in a sling. A postoperative radiograph is taken (Fig. 23-43).
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FIGURE 23-43 Postoperative radiograph showing a noncemented Delta Xtend prosthesis.
Postoperative Rehabilitation
If a deltopectoral approach is used, the patient may start active range of motion the day after surgery and use the arm as much as the pain allows. If the subscapularis has been repaired, the external rotation is restricted to neutral the first 6 weeks. If a deltoid-splitting approach has been used, passive range of motion is started the day after surgery. The patient has the arm in a sling for 2 to 3 weeks. The patient may use the arm for easy activities of daily living after 2 to 3 weeks and may start assisted active range of motion at the same time. The patient gradually increases to free active range of motion 4 to 5 weeks after surgery. The patient should not use the operated arm to push up from sitting to standing the first 6 weeks postoperatively.
Overall Results CTA-Head Hemiarthroplasty

Because this specific hemiarthroplasty for cuff-deficient arthritic shoulders has only been available for a short time, as of late 2008, only oral presentations had been made and one paper submitted to a peer-reviewed journal. Basamania [65] has performed more than 200 implantations, Trail [64] has experience with more than 80 hemiarthroplasties, and in our institution we have followed 21 patients with a follow-up more than 24 months. [46] These 21 patients had a cuff tear arthropathy type Ia, Ib, or IIa. None of them had completely unbalanced
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and decompensated rotator cuff tears. That means that all of them had a preoperative active elevation of more than 100 degrees and they had a functioning subscapularis, which means that the belly press test was negative or maximum 1 degree positive and the preoperative MRI did not show higher grades of subscapularis atrophy or fatty degeneration (Fig. 23-44). We did a prospective clinical study with clinical and radiologic followup immediately after surgery and at 6, 12, 24, and 36 months. The age- and sex-corrected Constant score at latest follow-up, with a minimum follow-up of 24 months, was 75. The mean active elevation was 112 degrees. Patients with a type Ia or Ib cuff tear arthropathy demonstrated a constant clinical result with minimal superior migration of the center of rotation over the complete follow-up period (Fig. 23-45).
FIGURE 23-44 Typical indication for cuff tear arthropathy (CTA): a 55-year-old man with balanced (compensated) rotator cuff defect. A, Type Ia cuff tear arthropathy (minimal superior migration, no significant instability). B, Preoperative MRI shows some atrophy and secondary fatty degeneration of the superior part of the subscapularis and infraspinatus and advanced atrophy of the supraspinatus. C, Radiograph taken 6 months after surgery shows a centered joint without any signs of superior migration.
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FIGURE 23-45 An 81-year-old man with type IIa cuff tear arthropathy. A, Preoperative (left) and immediate postoperative (first day) (right) radiographs. The postoperative radiograph shows good centering of the head. The patient experienced nearly no superior migration due to weakness of the deltoid postoperatively because of a continuous postoperative indwelling interscalene catheter delivering pain therapy. B, Same patient 6 months after surgery. Left, Radiograph shows some superior migration of the head. Center and right, Photographs show a very good clinical result. C, Same patient 2 years after surgery. The radiographs show increasing superior migration, but the photographs show a still very good clinical result. There is no anterosuperior translation in the Y view (right radiograph), proof of a good functioning subscapularisinfraspinatus force couple.
In patients with a type IIa arthropathy, we sometimes could observe a slow decrease of the Constant score values and increasing superior migration with the development of a type IIb instability. A revision to a reverse shoulder arthroplasty was necessary in two patients due to a secondary subscapularis tendon failure. In both cases there was a history of prior rotator cuff surgery with acromioplasty and coracoacromial ligament detachment (Fig. 23-46).
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FIGURE 23-46 Failed cuff tear arthropathy (CTA) head arthroplasty. A, Radiograph 6 months after surgery shows a stable joint; the patient had good clinical function. Double-headed arrow indicates distance between humeral head and coracoid process. B, Radiographs 12 months after treatment show slight superior migration and significant anterior displacement. Arrow indicates contact between humeral head and coracoid process. C, Fluoroscopy 12 months after surgery demonstrates dynamic anterosuperior instability. Deterioration of function was indicated by a positive belly press sign. Revision surgery proved failure of the subscapularis tendon. Arrow indicates degree of superior migration.
Reverse Shoulder Arthroplasty

The Grammont Delta reverse shoulder prosthesis has been used for almost 20 years. Several studies have evaluate this prosthesis for rotator cuffdeficient arthritic joints. No instability was found in these studies. Reports of Bouttens [76] on 39 patients with rotator cuff tear arthropathy with 5-year follow-up and Favard [77] on 15 patients with 25 months of follow-up showed excellent results with regard to pain reduction and improvement of active range of motion, with only one case of aseptic glenoid loosening in the Bouttens study. Jacobs and colleagues [78] published their results with the use of the Delta Grammont reverse shoulder prosthesis in seven patients with rotator cuff arthropathy. They found an increase in the mean Constant score from 17.9 preoperatively to 56.7 postoperatively, with a mean follow-up of 16 months. Boulahia [79] reported significant reduction of pain and significant improvement in forward elevation and function with the Delta reverse shoulder prosthesis in 16 patients with arthritic shoulder joints and irreparable rotator cuff tears, with one case of glenoid loosening.
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Rittmeister and colleagues [80] reported the use of Grammont reverse shoulder prosthesis in eight rheumatoid arthritic shoulders with nonreconstructive rotator cuff lesions. They found significant pain reduction and active range of motion improvement at a mean follow-up of 54 months (range, 41-79 months). The Constant score improved from a mean of 17 points preoperatively to a mean of 63 points. However, two patients developed clinically significant aseptic loosening of the glenoid component. In three patients, operated through a transacromion approach, a refixation of the acromion was needed shortly after the primary surgery. The refixation problem was solved when a deltopectoral approach was used. The reverse shoulder design does have potential benefits with good results shown for the early and midrange follow-up periods, [45,81,82] especially when rotator cuff arthropathy patients are separated from those of rheumatoid arthritis. Some recent studies have had larger series of cuff tear arthropathy patients and longer follow-ups are reported. In these studies, the good clinical outcome in a midterm perspective could be confirmed. [14,30,45,7274,83] In 2006 the results of 457 patients who had surgery between 1992 and 2002 were published in a French multicenter study. [86] The results of a continuous prospective clinical and radiologic follow-up study of more than 400 reverse shoulder arthroplasties performed between 1997 and 2006 at our institution were also presented. [45,46] A few more peer-reviewed clinical outcome papers have been published since 2004. [30,72,74] The outcome and the results of all these studies have a very uniform message: Despite the difficult preoperative condition of the joint and rotator cuff, the clinical outcome is unexpectedly good; there is a significant difference in clinical outcome dependent on the underlying indications; and the results for cuff tear arthropathy are superior to revisions of failed hemiarthroplasties or total arthroplasties and superior to reverse shoulder arthroplasty for fracture sequelae. For cuff tear arthropathy indications, the reported overall Constant scores are 55 to 65 points, which means an age- and sex-related value of 80% to 95% in this specific elderly population. Concerning range of motion and function, the reverse shoulder arthroplasty restores active elevation but not active rotation in completely cuff-deficient shoulders. The gain in active flexion is surprisingly high in the cuff tear arthropathy group; postoperative values range from 110 to 140 degrees for this patient group. If some parts of the posterior cuff (inferior third of the infraspinatus and teres minor) are still functioning, the external rotation function is also acceptable, and the patient has gained a good external rotation in the space (abduction) and an external rotation of 15 to 20 degrees with the arm at the side, but no improvement of external rotation in comparison to preoperatively could be expected. A common problem is the limited amount of achievable internal rotation (active and passive), which is directly related to the reverse prosthesis design and implantation technique. [14] Theoretically, the amount of accessible internal rotation is getting better with a more anteverted orientation of the humeral component. [84] An extremely anteverted deviation from the physiologic retroversion is limited by the bony geometry of the head anteriorly and would also increase the existing headshaft offset of the humerus in the posterior direction.
Long-Term Results
The good clinical results seem to deteriorate after 6 to 7 years. [72,85] The survivorship is significantly worse in the revision group or in the fracture-sequelae group. Whether this is in a direct connection with the concurrent progression of inferior glenoid bone erosion (inferior notching) is still under discussion. [16,75] Simovitch [16] has proved that the clinical results are significantly worse in patients with higher grades of glenoid notching. The French multicenter study group, on the contrary, found no correlation between notching and clinical outcome. It is not clear whether inferior notching is a precursor or warning sign of threatening glenoid component loosening. Indirect proof of the risk potential of high-grade inferior notching is the parallel increase of higher degrees of notching and revisions for component loosening after 6 years. Although notching is not yet a proven precursor of loosening, it should not be considered a harmless and unavoidable phenomenon of reverse shoulder arthroplasty. Notching should be considered a result of the extra-anatomic design of Grammont's reverse prosthesis, where the hemisphere is directly positioned on the glenoid surface. Numerous studies report notching rates from 40% to 100% (Table 23-3). The degree of notching is graded in five types, where grade 3 is erosion beyond the inferior screw, indicating evolution, and grade 4 is erosion under the base plate as a first sign of loosening (see Fig. 23-6). Interestingly, Simovitch [16] has shown that in addition to inferior notching in 44% of the cases, 8% had anterior notching and 30% had posterior notching. Whether the inferior glenoid notching should be considered a complication or an inevitable sequela of Grammont's type of reverse shoulder arthroplasty is still under discussion.
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TABLE 23-3 -- Inferior Glenoid Notching in Reverse Shoulder Arthroplasty Notching (Distribution %) [*] Author Boulahia et al [79] Capon [91] Favard et al [26] Follow-up (mo) 0 16 42 45 39 42 67 44 44 60 38 1 2 3 4
61.1 % notching, 1 loosening 10.5 21 45.6 17.6 5.3
65% notching, 2 loosening 5.9 40 22 18 32.4 13.6 4 15.7 22 25.1 8 33.8 36.4 54 58.9 17.9 1.9 18 12 8
Seebauer [45] Levigne et al [75] Bouttens and Simovitch et Nrot [76]
33.4 15.1 4.4 18 16 3 3.9
al [16]
Sirveaux et al [30] Valenti et al [92] Werner et al [74]
22.1 7.8
13.6 36.4 0 42
* According to Sirveaux et al. [30]
Indisputably, higher grades of inferior notching are increasing with time, and in the follow-up period of 6 to 10 years, a significant increase can be observed. However, there is no proven statistical connection between the increase in the notching phenomenon and the concurrent significant increase in frequency of unsatisfactory clinical results (Constant score <30) and revision rate. [85] However, published studies with larger numbers of patients are needed to evaluate the rate of glenoid loosening.
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TREATMENT from Rockwood: The Shoulder on MD Consult

Rockwood: The Shoulder, 4th ed. TREATMENT

TREATMENT from Rockwood: The Shoulder on MD Consult

Anatomic Unconstrained Arthroplasty Total Shoulder Arthroplasty

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

Seebauer's Preferred Approach: CTA-Head Hemiarthroplasty Indications

Anesthesia and Patient Positioning

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

FIGURE 23-18 Head resection. A, Extramedullary. B, Intramedullary guided.

TREATMENT from Rockwood: The Shoulder on MD Consult

Preparation of the Greater Tuberosity

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

Implantation and Subscapularis Reattachment

TREATMENT from Rockwood: The Shoulder on MD Consult

Ekelund's Preferred Approach: Reverse Arthroplasty

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

FIGURE 23-29 The cutting jig is applied.

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

Preparation of the Humerus

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

FIGURE 23-38 Trial humeral component.

TREATMENT from Rockwood: The Shoulder on MD Consult

FIGURE 23-39 Trial glenosphere in place.

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

FIGURE 23-43 Postoperative radiograph showing a noncemented Delta Xtend prosthesis.

Overall Results CTA-Head Hemiarthroplasty

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

Reverse Shoulder Arthroplasty

TREATMENT from Rockwood: The Shoulder on MD Consult

TREATMENT from Rockwood: The Shoulder on MD Consult

61.1 % notching, 1 loosening 10.5 21 45.6 17.6 5.3

Seebauer [45] Levigne et al [75] Bouttens and Simovitch et Nrot [76]

33.4 15.1 4.4 18 16 3 3.9

Sirveaux et al [30] Valenti et al [92] Werner et al [74]

* According to Sirveaux et al. [30]

Copyright 2008 Elsevier Inc. All rights reserved. - www.mdconsult.com

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